Doctors draw payments from drug companies

Judith Graham, Tribune reporter

Follow drug company money in Illinois, and it leads to the psychiatry department at Rush University Medical Center, a prominent headache clinic on the North Side of Chicago, a busy suburban urology practice and a psychiatric hospital accused of overmedicating kids.

In each of these settings, doctors are drawing an extra paycheck — worth tens of thousands of dollars a year or more — for speaking to other medical professionals about pharmaceutical products at company-sponsored, company-scripted events in Illinois and across the country.

The extent of these activities is only now coming to light as drug companies start publicly releasing data about their relationships with physicians, information that until now has been a closely guarded secret.

The pharmaceutical data show that 11 Illinois physicians each earned more than $100,000 between January 2009 and June 2010 from seven companies, according to a new database compiled by the national investigative news organization ProPublica. An additional 13 medical providers earned between $75,000 and $100,000, primarily for participating in speakers' bureaus and educational forums. Most doctors received far lesser sums.

This medical moonlighting is perfectly legal but highly controversial.

Doctors and drug companies say their collaborations provide time-pressed medical professionals with much-needed education about how best to treat illnesses and how various drugs work. But other medical and policy experts say physicians involved in the activities have crossed an important line, straying into the realm of product promotion and potentially compromising their independence and patient care.

"Let's be honest: The purpose of these talks is to influence doctors to buy a company's drugs," said Eric Campbell, an associate professor of health policy at Harvard Medical School.

That may raise potential problems if patients are prescribed medications that are not necessary, are needlessly expensive or are not appropriate for their conditions.

Dr. Catherine DeAngelis, editor of the Journal of the American Medical Association, criticized the speaking arrangements, saying they posed "a conflict of interest" and threatened to put doctors' "own financial benefit before that of the patients who trust them."

More than a dozen physicians interviewed by the Tribune explained that they work with drug companies because they enjoy teaching other practitioners about important medications and the research behind them. None of the physicians routinely tells patients about his or her drug company-sponsored activities, and all said they believe such ties have no effect on their medical practices.

"To me, it's always been about helping physicians understand the treatments that are available for migraine," said Dr. Merle Diamond, president of the Diamond Headache Clinic on the North Side.

Diamond received $148,300 this year and last, mostly for speaking on behalf of GlaxoSmithKline. Four colleagues listed on her headache clinic's Web site received lesser sums from Glaxo.

Dr. David Guthman, a urologist who practices in Arlington Heights, earned more from these pharmaceutical firms than any other Illinois physician — $210,091 this year and last. The sum includes $195,750 from Glaxo for discussing medications for enlarged prostates and bladder dysfunction.

"I will not speak for a drug that I don't believe in wholeheartedly," Guthman said. "I would argue we're helping health care by avoiding misuse of drugs."

The ProPublica database draws from information posted online by Eli Lilly and Co., Pfizer Inc., AstraZeneca, GlaxoSmithKline, Merck & Co. Inc., Johnson & Johnson and Cephalon Inc. Several companies released data about their relationship with physicians in the wake of legal settlements related to allegedly fraudulent marketing activities. ProPublica gathered the information in one place and made it easy to search by a doctor's name or home state.

All pharmaceutical and medical device firms will be required to make similar disclosures by 2013 under the Physician Payments Sunshine Act, passed as part of national health reform earlier this year. Because dozens of drug companies haven't reported data yet, some doctors may be making much more than the sums disclosed to date.

In Illinois, Eli Lilly spent the most money — nearly $4 million — on doctors and a small number of nurses who speak for the company.

"When it comes to this kind of expert scientific and product knowledge, physicians really like to hear from other physicians," spokesman J. Scott MacGregor said.

But several medical experts say the true agenda is to sway doctors to use products featured at company-sponsored sessions — typically newer, brand-name medications that may cost more than alternatives without being substantially more effective.

"Do you think drug companies would spend millions of dollars on this if it didn't serve their interests?" DeAngelis said.

Angela Maher, a former Michigan drug sales representative turned whistle-blower, described training sessions where psychologists and coaches would brief her on how to play on doctors' vulnerabilities — their desire to feel important, their eagerness to be on the cutting edge — while working to boost sales.

Each time a physician would give a talk, Maher would fill out a "return on investment" spreadsheet tracking prescription trends for all the doctors who attended the event. If sales went up, the speaker was asked to give another presentation, she said. If not, further invitations to speak would not be extended. Over a 13-year period, Maher worked for four drug companies.

Both the Institute of Medicine, which published a major report on conflicts of interest in medicine last year, and the Association of American Medical Colleges have voiced concerns and suggested that doctors be discouraged from participating in company-sponsored speakers bureaus, especially when lectures are prepared by companies, which most now are.

Many doctors told the Tribune that the U.S. Food and Drug Administration approves presentations in advance. That is not the case. The agency requires companies to submit materials only on the day they're used, said Tom Abrams, director of the FDA's division of drug marketing, advertising and communications. Some but not all are then reviewed after the fact.

Dr. Nada Stotland, of Chicago, a former president of the American Psychiatric Association, said she worries doctors are deceiving themselves about the potential for manipulation.

Studies have shown that even small sums can influence physicians, usually unconsciously, and alter prescribing habits, she said. Yet while physicians recognize that colleagues may be susceptible to influence, they tend to deny any personal vulnerability, she said.

"The implication that care of their patients — which they feel is of the utmost importance — could be compromised feels profoundly insulting," Stotland said. "It's clear that the companies that make gifts and payments to doctors know a lot more about how this works than the recipients."

Dr. Corey Goldstein, a psychiatrist who does research at Rush University Medical Center and also has a private practice, earned $144,578 from Lilly and Astra Zeneca in 2009 and the first half of 2010.

"I have never ever felt biased in any way whatsoever regarding my speaking and how I treat patients. … I prescribe the most appropriate medications for each individual patient," he said.

But Goldstein expects to stop speaking for pharmaceutical firms by year's end, in part because Rush is changing its conflict-of-interest policies. Beginning next September, all doctors affiliated with Rush will be prohibited from giving lectures that are controlled by an outside commercial entity with the purpose of marketing products.

"We've decided that even though physicians do get educated at these events, what they really are is a way of promoting a company's products and, insofar as that is the intent, there is a conflict of interest for our faculty," said Dr. David Ansell, the medical center's chief medical officer.

The change will have a big impact on Rush's psychiatry department. Three of the Illinois doctors earning the most money from the drug companies now providing information — Goldstein, Dr. John Zajecka and Dr. Roueen Rafeyan — are psychiatrists affiliated with Rush, and several others also are earning substantial amounts.

Rafeyan, who earned $203,936 from four drug companies in 2009 and 2010, said he doesn't know what he'll do when Rush's prohibition goes into effect. The psychiatrist spends much of his time serving poor patients, he said, and speaking for drug companies helps keep his practice afloat.

As in other states, psychiatrists dominate the list of Illinois doctors who earn large amounts from drug companies. Among them is Dr. Joseph P. McNally, medical director of Streamwood Behavioral Health Center, with $72,378 in payments from Lilly.

In an interview, McNally said, "I in no way influence prescribing practices of my peers" at Streamwood, where 10 child psychiatrists are on staff.

The drug he most often talks about — Lilly's Strattera, approved for patients with attention deficit hyperactivity disorder — is a "second-line therapy" at Streamwood that can be prescribed only when a preferred therapy fails, McNally said.

Late last year, a review by experts from the University of Illinois at Chicago found that the psychiatric hospital sometimes gave foster children housed at the facility dangerous combinations of mood-altering drugs. Streamwood officials called the report "exaggerated and misleading."

What are patients to make of the data about physician payments?

Dr. Carl Elliott, a professor of bioethics at the University of Minnesota, said he doesn't think the information is very useful. Few patients are likely to look up their doctors and risk embarrassment by inquiring about the doctor's activities during an exam, he said.

But Dr. Sidney Wolfe, director of the health research group at Public Citizen, an advocacy group, disagrees.

"Patients have every reason to ask their physicians if they take money from a drug company," he said. "If the answer is yes, ask them why and what this means for you."